Which nursing intervention has the highest priority for the nurse who provides care for a patient receiving oxygen from a non-rebreathing mask?
A) Posting a no smoking sign over the patient's bed
B) Applying an oil-based lubricant to the patient's mouth and nose
C) Assessing the patient's respiratory status, orientation, and skin color
D) Changing the mask and tubing daily
Ans: C
Chapter: 25
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Patient Needs: D-4
Feedback: Non-rebreathing masks can deliver high concentrations of oxygen to patients in acute respiratory distress. Assessment of a patient's status is a priority for determining the effectiveness of therapy. Equipment should be changed daily, but this has a lower priority. Oil-based lubricants can cause pneumonia by promoting bacterial growth. Smoking is a fire hazard and is prohibited in hospitals regardless of whether the patient is receiving oxygen from a non-rebreathing mask.
You might also like to view...
Identify the step in the nursing process that interfaces with the statement that critical thinking enhances the ability to better understand someone else
1. Assessment 2. Nursing diagnosis and outcome identification 3. Planning 4. Implementation
In the early 1800s, it became clear that the standardization of drug purity and strength was necessary. Which reasons reflected this need?
1. Strength and purity of products varied from region to region and batch to batch. 2. Strength and purity of products depended on the pharmacist's experience. 3. Strength and purity of products would vary in size, taste, and nutritional value. 4. Strength and purity were mostly guaranteed if products were produced locally, which caused a hardship for those outside the region. 5. Strength and purity could be trusted when the product had gone through extensive local testing.
A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client asks for assistance with a shower. Which comment by the nurse is the most appropriate?
1. "If you look better, you might feel better." 2. "Taking a shower might wash away some of that gloom and doom." 3. "This is a positive sign. I'll be right back with your supplies." 4. "Your spouse will be glad to see that you're feeling better."
A nurse is teaching psychosocial development to a group of adolescents. The nurse expects teens in which stage of adolescence to be most able to recognize S T I s and pregnancy as risks of unprotected sex?
1. Preadolescense 2. Early adolescence 3. Middle adolescence 4. Late adolescence